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A preventable fate: 
The failure of ART 
scale-up in 
Myanmar
MSF report
November 2008The situation for many people living with HIV in Myanmar is critical 
due to a severe lack of lifesaving antiretroviral treatment (ART). MSF 
currently provides ART to more than 11,000 people. That is the majority 
of all available treatment countrywide but only a small fraction of what is 
urgently needed. For five years MSF has continually developed its HIV/
AIDS programme to respond to the extensive needs, whilst the response 
of both the Government of Myanmar and the international community 
has remained minimal. MSF should not bear the main responsibility for 
one of Asia’s most serious HIV/AIDS epidemics. Pushed to its limit by 
the lack of other services providing ART, MSF has had to make the pain-
ful decision to restrict the number of new patients it can treat.  With few 
options to refer new patients for treatment elsewhere, the situation is dire. 
 
An estimated 240,0001 people are currently infected with HIV in Myanmar. 
76,000 of these people are in urgent need of ART, yet less than 20 %2 of 
them receive it through the combined efforts of MSF, other international 
non-governmental organizations (NGOs) and the Government of Myan-
mar.  For the remaining people the private market offers little assistance 
as the most commonly used first-line treatment costs the equivalent of 
a month’s average wage. The lack of accessible treatment resulted in 
25,000 AIDS related deaths in 2007 and a similar number of people 
are expected to suffer the same fate this year, unless HIV/AIDS services 
- most importantly the provision of ART - are urgently scaled-up. 
The Government of Myanmar and the International Community 
need to mobilize quickly in order to address this situation. Cur-
rently, the Government spends a mere 0.% of the gross domestic 
product on health, the lowest amount worldwide4, a small portion 
of which goes to HIV/AIDS. Likewise, overseas development 
aid for Myanmar is the second lowest per capita worldwide45 and 
few of the big international donors provide any resources to the 
country. Yet, 189 member states of the United Nations, includ-
ing Myanmar, endorsed the Millennium Development Goals, 
including the aim to “Achieve universal access to treatment for 
HIV/AIDS for all those who need it, by 2010”. As it stands, this 
remains a far cry from becoming a reality in Myanmar. 
 
As an MSF ART patient in Myanmar stated, “All people must have 
a spirit of humanity in helping HIV patients regardless of nation, 
organization or government.  We are all human beings so we must 
help  each other”. Unable to continue shouldering the primary 
 This is based on an estimated HIV prevalence range in the adult population (5 to 49 
years) of between 0.5-0.9%, with a mid point of 0.67%. According to UNAIDS, the 
2007 estimates, which are a reduction in previous estimates where in 2004 the midpoint 
was 1.3% of adult population, are finer analysis of existing data using EPP software and 
not related to the impact of public health interventions.
2 UNAIDS Report for the Global AIDS epidemic 2008
 UNAIDS Report for the Global AIDS epidemic 2008
4 United Nations Development Programme (UNDP) 2008
5 UNDP-comparing the bottom 50 countries in the Human Development Index
Executive 
Summary
“I think that I am going to die. 
I cannot do anything to get 
better. Even if there is a 
treatment I am not able to 
afford it, as I do not have 
money. So I think that I will 
die from HIV”
28 year old male, Myanmar, 2008
12
responsibility for responding to one of Asia’s worst HIV crises, 
MSF insists that the Government of Myanmar and international organi-
zations urgently and rapidly scale-up ART provision. A vast gulf exists 
between the needs related to HIV/AIDS and the services provided. 
Unless ART provision is rapidly scaled-up many more people will 
needlessly suffer and die. 
  3
ART Coverage at end 2007 by country
Source: UNAIDS  Towards Universal Access 2008
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Myanmar Vietnam ThailandCambodia
Laos
SE Asia av.
Myanmar is experiencing one of Asia’s most serious HIV epidemics, yet 
the available care and treatment meets only a fraction of the needs. As 
a result people are dying unnecessarily, people who are desper-
ate to live and contribute to their family, community and coun-
try. An estimated 240,0006 people are thought to have HIV in 
Myanmar. Of these people, 76,000 are in urgent need of lifesav-
ing antiretroviral therapy, yet less than 20% of those in need of 
treatment receive it7. This is one of the lowest coverage rates for 
ART coverage worldwide8.  
As it stands, MSF provides ART to more than 11,000 peo-
ple, which makes up the majority of all available treatment 
countrywide. The Government of Myanmar and other non-
governmental organizations (NGOs) provide ART to around  
4,000 people9. While there are a number of NGOs working 
in HIV/AIDS in the country, efforts are largely focused on 
the provision of care rather than treatment. Although well 
meant, care alone can only support people in dying, whereas 
ART can assist people to live. Having put significant re-
sources into its Myanmar programme, MSF can no longer 
continue to scale-up ART provision, in the face of so little 
response by other actors. Therefore, it has had to make the 
painful decision to 
restrict the number 
of new patients it can 
treat. With few op-
tions to refer new 
patients for treatment 
elsewhere, the situa-
tion is dire. 1
 
For the thousands of 
people unable to access 
free ART there are very 
few other options open to 
them. The cost per month 
of the most commonly 
used first-line ART in a 
private pharmacy
6 This is based on an estimated HIV prevalence range in the adult population (5 to 49 
years) of between 0.5-0.9%, with a mid point of 0.67%. According to UNAIDS, the 
2007 estimates, which are a reduction in previous estimates where in 2004 the midpoint 
was 1.3% of adult population, are finer analysis of existing data using EPP software and 
not related to the impact of public health interventions
7 UNAIDS Report for the Global AIDS epidemic 2008 
8 UNAIDS 2008 Progress Report ‘Towards Universal Access’. The figure is based on 
countries that have over 5,000 people who require ART according to this report.  The 
other 9 countries with the lowest ART coverage are: Chad, Eritrea, Iran, Liberia, Nepal, 
Niger, Pakistan, Sudan, Ukraine
9 According to interviews with other organisations, MSF, 2008
HIV/AIDS in 
Myanmar at 
Crisis Point
ART coverage end 2007. Comparison with nearby countries4
in Myanmar is $2910.  This is far beyond the means of most 
people who on average live on $1.2 per day11.  Even if people 
can find a way to afford ART many often become indebted 
and are soon forced to stop. This leaves families not only with 
the trauma of losing a loved one, often the main income-pro-
vider for the family, but also with crippling debt. Alternative-
ly, some patients are only able to source treatment irregularly, 
when finances allow or family and friends assist. This can 
lead to the rapid development of drug resistance.  1 
10 MSF data for 1 month supply of Lamivudine, Stavudine & Nevirapine in a private 
pharmacy in Yangon, October 2008 priced at Khat 5,000( USD=,200 Khat).  If pa-
tients have side effects to Nevirapine, which is common, and need to move to Efavirenz  
then the price triples to 00,000 Khat
11 Economist Intelligence Unit (EIU) estimate the GDP per capita of $435 per year in 
Myanmar-2008
“If I have the opportunity 
to get ART, I will make an 
offering.  After I got healthy, 
I would work more and would 
try to get back some of my 
possessions. I will help my 
mother to live happily.  After 
I got healthy, I would run my 
business like before.”
28 year old, Female, Myanmar, 20085
On the one hand, Myanmar has a weak and under-funded state health-
care system.  The Government of Myanmar spends a mere 0.% of its 
gross domestic product on health, the lowest amount worldwide12.  In 
2007 the Government spent just USD$ 0.7 per person on health,1 with 
the 2008 annual HIV/AIDS budget estimated at just USD$ 200,000 in 
total.  With growing revenue from oil and gas exports, the Government 
must invest more in its ailing health system and specifically HIV/AIDS 
care and treatment.  
On the other hand, overseas development aid (ODA) to Myanmar 
is the second lowest per capita worldwide, after India14.  Compared 
to some of Myanmar’s neighbouring countries it receives a tiny 
fraction of the ODA they do. Few of the big international donors, 
such as the Global Fund, World Bank, Asian Development Fund, 
and the President’s Fund invest in the Government health system 
out of concern over the effective use of funds.  Whatever their 
reasons, there is a massive under-investment in assistance in 
Myanmar and it is the general population who are suffering and 
will continue to suffer unless this changes.
Other international actors, including NGOs, who could fund 
HIV/AIDS treatment and care in Myanmar have been hesitant. 
This may be due to concerns that the substantial improvements in 
the Government health system necessary to facilitate an eventual 
hand-over of patients will not materialize. Alternatively, organizations 
1 
12 United Nations Development Program (UNDP) 2008. 
13 Myanmar Department of Health website for 2007 expenditure on health per person 
per year of 849 Kyat (using  USD= 200 Khat)
14 UNDP-comparing the bottom 50 countries in the Human Development Index
A lack of 
resources and 
commitment 
Source (Cambodia): Cambodia GFATM Round 6 AIDS proposal
Overseas Development Assistance (ODA) funding 
per capita in selected Asian countries6
may be put off by the challenges posed by working in a country 
like Myanmar, including official constraints and difficult bureau-
cratic procedures. In some areas of the country, such as Kayah 
state, MSF has not been permitted to start AIDS treatment.  These 
legitimate concerns however should not dissuade organizations 
from providing assistance where it is most needed. MSF has 
proven that providing independent and effective humanitarian 
assistance to people in Myanmar is possible and more to the point 
critical if unnecessary deaths are to be prevented. 
Correlation of Gross National Product (GNI) and Overseas Development Assistance 
(ODA) per capita in relation to population size
Source: OECD Development Assistance Committee (DAC), data 2005. Myanmar is 
one of the lowest recipients of ODA and also has one of the lowest GNI per capita7
MSF has provided essential healthcare services in Myanmar 
since 199 and began a programme to support people living 
with HIV/AIDS in 2003. Since then, MSF staff has assisted 
thousands of HIV patients, working from 2 clinics, in five 
areas throughout the country. Services include counseling, testing, 
treatment of opportunistic infections, nutritional support, health 
education and most importantly antiretroviral treatment.   
At the time of publishing this report, MSF provides ART to more 
than 11,000 patients.  Patients are selected independently, purely 
on medical grounds and without political interference. Medicines 
are distributed directly to the patient.  Monitoring of the pro-
gram is done at the level of the beneficiary; an essential element 
of the program that helps to guarantee that the population 
benefits directly from MSF’s services and that donor money is 
spent transparently.
Having made an enormous effort to respond to the overwhelming 
need for ART treatment during the last five years, MSF can no longer 
take primary responsibility for ART scale-up in Myanmar. Pushed 
to its limit by the lack of treatment on offer by other care 
providers, MSF has recently been forced to make the painful 
decision to drastically reduce the number of new patients it 
can treat. With few options to refer new patients for treatment 
elsewhere, the situation is traumatic for both patients and staff.   
MSF 
in Myanmar
“It is not OK for us.   
We cannot bear this burden. 
Sometimes I wake up at 
midnight and dream of my 
patients. Women who come 
in and are HIV positive – they 
have three children at home 
and the husband has passed 
away and we cannot provide 
any treatment for them”. 
MSF National Staff Doctor, 20088
MSF calls for all sectors to urgently and rapidly scale-up lifesaving 
HIV/AIDS treatment in Myanmar, in the face of overwhelming needs. 
The public sector, through the Myanmar Department of Health 
(DoH),  must take the lead and drive the scale-up of HIV/AIDS 
services, most importantly ART, with the support of international 
donors and organizations. 
During the last two years, the DoH has treated patients with ART 
in 22 hospitals around the country, treating an estimated 1,80015 
people. This covers just a fraction of the needs, but is a good basis 
on which to develop services. DoH is the only actor with long-
term potential to provide sustainable ART nationally.  At present 
some of the DoH ART sites have a limit of just 20 patients.  Such 
low numbers are not cost-effective and make the initial invest-
ment in set-up, training and ongoing drug supply hard to justify 
unless numbers are increased considerably.  Once a site is estab-
lished there need to be ambitious plans set to expand care and 
treatment. DoH has shown signs of wanting to develop its servic-
es in HIV/AIDS and must be supported to realize these ambitions. 
Geographical coverage also needs to be expanded, in areas such 
as Chin and Kayah states, which have no ART programmess at 
all. In Kayah State, some AIDS patients are attempting to access 
treatment in neighboring Thailand, which makes them vulnerable 
to the development of drug resistance, since having to cross the 
border frequently means that reliable adherence to the medication 
is difficult. 
For those who are lucky enough to be able to afford ART on the 
private market, better advice and support needs to be available. 
Private practitioners are not always properly trained in prescrib-
ing medication for HIV/AIDS, which can cause serious problems 
for the patient. Therefore, proper training in HIV/AIDS care and 
treatment, supported by the provision of free-of-charge treatment, 
should be encouraged through the private sector.
To make scaling-up possible the Government of Myanmar desper-
ately needs to invest more in its health infrastructure and specifi-
cally allocate funds to tackle the HIV/AIDS crisis. Likewise, 
the international community needs to provide increased support 
similar to that allocated to HIV/AIDS programmes in other devel-
oping countries and in line with the needs. 
Alongside the Government of Myanmar’s need to redouble its 
efforts in scaling-up ART provision, it also needs to better facili-
tate the international community’s supporting role. Specifically, it 
should remove the constraints faced by NGOs which hampers
1 
5 Government of Myanmar: more than 500 patients were receiving ART by the end 
of 2007 and by the end of this year 800 patients should receive the treatment.
Urgent and Rapid 
Scale-up 
of HIV/AIDS 
Treatment Essential
“All people must have a spirit 
of humanity in helping HIV 
patients regardless of nation, 
organization or government.   
We are all human beings so 
we must help each other”. 
29 year old ART Patient, 20089
them from implementing HIV/AIDS programs and ensure im-
provements in bureaucratic procedures such as the signing of 
agreements and import of goods. 
In the year 2000, 189 member states of the United Nations, in-
cluding Myanmar, committed to working towards achieving the 
Millennium Development Goals, including the aim to “Achieve 
universal access to treatment for HIV/AIDS for all those who 
need it, by 2010”. As it stands, this remains a far cry from be-
coming a reality in Myanmar. It is the responsibility of all actors, 
national and international to stand-by their commitment to HIV 
sufferers in Myanmar and urgently scale-up HIV/AIDS services 
– most importantly ART, to put an end to the needless suffering 
and waste of life. 
“People affected by HIV/AIDS 
in Myanmar are desperate for 
more assistance. They want 
to live healthy and happy 
lives like any other. The 
ground-swell is there – HIV 
patient groups are forming 
around the country and our 
medical staff works tirelessly 
to assist patients. But it is just 
not enough, the problem is too 
big. Others must do more”.
MSF National Staff

A preventable fate: The failure of ART scale-up in Myanmar

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